MM, especially MIS on the head and neck, often exhibits an asymmetric growth pattern, making it quite suitable for treatment with MMS. The use of MART-1 immunostain may improve the diagnostic accuracy of Mohs surgeons. We believe that HMB-45 should not be used to rule out the diagnosis of MIS in equivocal sections because of its inferior sensitivity. We introduce a new mapping technique as an adjunctive measure to aid in the clinicopathologic evaluation of perilesional skin.

Our study lends support to the contention that clean, nonsterile gloves are safe and effective for use in the tumor extirpation phase of MMS, at a significant cost savings.

The trilobed flap offers a successful reconstructive option for Mohs defects of the distal nose that may not be optimally amenable to bilobed flap repair. Over 3 years, 31 trilobed flap repairs were performed with overall excellent outcomes.

IMPORTANCE Outlier physician practices in health care can represent a significant burden to patients and the health system. OBJECTIVE To study outlier physician practices in Mohs micrographic surgery (MMS) and the associated factors. DESIGN, SETTING, AND PARTICIPANTS This retrospective analysis of publicly available Medicare Part B claims data from January 2012 to December 2014 includes all physicians who received Medicare payments for MMS from any practice performing MMS on the head and neck, genitalia, hands, and feet region of Medicare Part B patients. MAIN OUTCOMES AND MEASURES Characteristics of outlier physicians, defined as those whose mean number of stages for MMS was 2 standard deviations greater than the mean number for all physicians billing MMS. Logistic regression was used to study the physician characteristics associated with outlier status. RESULTS Our analysis included 2305 individual billing physicians performing MMS. The mean number of stages per MMS case for all physicians practicing from January 2012 to December 2014 was 1.74, the median was 1.69, and the range was 1.09 to 4.11. Overall, 137 physicians who perform Mohs surgery were greater than 2 standard deviations above the mean (2 standard deviations above the mean = 2.41 stages per case) in at least 1 of the 3 examined years, and 49 physicians (35.8%) were persistent high outliers in all 3 years. Persistent high outlier status was associated with performing Mohs surgery in a solo practice (odds ratio, 2.35; 95% CI, 1.25-4.35). Volume of cases per year, practice experience, and geographic location were not associated with persistent high outlier status. CONCLUSIONS AND RELEVANCE Marked variation exists in the number of stages per case for MMS for head and neck, genitalia, hands, and feet skin cancers, which may represent an additional financial burden and unnecessary surgery on individual patients. Providing feedback to physicians may reduce unwarranted variation on this metric of quality.

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IMPORTANCE Mohs micrographic surgery (MMS) is a skin cancer treatment that uses staged excisions based on margin status. Wide surgeon-level variation exists in the mean number of staged resections used to treat a tumor, resulting in a cost disparity and question of appropriateness. OBJECTIVE To evaluate the effectiveness of a behavioral intervention aimed at reducing extreme overuse in MMS, as defined by the specialty society, by confidentially sharing stages-per-case performance data with individual surgeons benchmarked to their peers nationally. DESIGN, SETTING, AND PARTICIPANTS This nonrandomized controlled intervention study included 2329 US surgeons who performed MMS procedures from January 1, 2016, to March 31, 2018. Physicians were identified using a 100% capture of Medicare Part B claims. The intervention group included physicians affiliated with the American College of Mohs Surgery, and the control group included physicians not affiliated with the American College of Mohs Surgery. INTERVENTIONS Individualized performance reports were delivered to all outlier surgeons, defined by the specialty society as those with mean stages per case 2 SDs above the mean, and inlier surgeons in the intervention group. MAIN OUTCOMES AND MEASURES The primary outcome was surgeon-level change in mean stages per case between the prenotification (January 2016 to January 2017) and postnotification (March 2017 to March 2018) periods. A multivariable linear regression model was used to evaluate the association of notification with this surgeon-level outcome. The surgeon-level metric of mean stages per case was not risk adjusted. The mean Medicare cost savings associated with changes in practice patterns were calculated. RESULTS Of the 2329 included surgeons, 1643 (70.5%) were male and 2120 (91.0%) practiced in metropolitan areas. In the intervention group (n = 1045), 53 surgeons (5.1%) were outliers; in the control group (n = 1284), 87 surgeons (6.8%) were outliers. Among the outliers in the intervention group, 44 (83%) demonstrated a reduction in mean stages per case compared with 60 outliers in the control group (69%; difference, 14%; 95% CI of difference, −1 to 27; P = .07). There was a mean stages-per-case reduction of 12.6% among outliers in the intervention group compared with 9.0% among outliers in the control group, and outliers in the intervention group had an adjusted postintervention differential decrease of 0.14 stages per case (95% CI, −0.19 to −0.09; P = .002). The total administrative cost of the intervention program was $150 000, and the estimated reduction in Medicare spending was $11.1 million. CONCLUSIONS AND RELEVANCE Sharing personalized practice pattern data with physicians benchmarked to their peers can reduce overuse of MMS among outlier physicians.

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BACKGROUND The paramedian forehead flap (PFF) is a well-established technique for reconstruction of large nasal defects. The literature has provided several technical advances and procedural nuances that expand the surgeon's options when performing this procedure.OBJECTIVE The objective is to provide procedural nuances, technical tips, and suggestions for improving flap outcomes. Specific techniques such as extending flap length below the orbital rim, avoiding terminal scalp hair inclusion in the flap design, restoring lining to full-thickness defects, and even flap dressings and wound care are detailed here. Of particular importance, the 3-staged turnover forehead flap for wounds requiring nasal lining, with delayed flap sculpting and cartilage graft placement, has revolutionized the conceptual approach to the most complicated nasal defects, and the technique is described in detail.METHODS This article includes the techniques and approaches from 3 different surgeons at 3 different institutions with 3 different training backgrounds, in an effort to provide a nuanced and broad overview of the subject matter.